The Symptomatic Accessory Navicular Bone

Gregory Strayhorn, MD, MPH, and James Puhl, MD Chapel Hill, North Carolina, and Iowa City, Iowa

The accessory navicular bone may serve as a nidus for in­ flammation and irritation of the medial aspect of the foot. When symptoms occur, the presence of the bone is frequently misdiagnosed as a fracture of the navicular bone. Conservative treatment of the symptoms associated with the accessory na­ vicular bone may not permanently resolve the inflammation and discomfort. When conservative therapy is ineffective, ex­ cision of the accessory navicular bone is the treatment of choice to alleviate pain and disability.

It has been reported that 10 to 14 percent of rather than as affecting the normal mechanics of normal feet have an accessory navicular bone.1 the foot.2,5 Other reports have estimated a 5 percent preva­ lence in the general population.2 The accessory navicular bone has been implicated in the produc­ Anatomy tion of a weak, painful foot.3 It was once thought The accessory navicular bone is located poste­ that the bone interfered with the normal mechan­ rior medially behind the tuberosity of the navicular ics of the foot because its relationship to the pos­ bone and is found unilaterally or bilaterally. The terior tibialis tendon then led to the development accessory navicular bone may be independent of of the flat foot.4 More recent studies have refuted the navicular bone, form a fibrocartilaginous union, the theory that the accessory navicular bone inter­ or form a natural bony union with the navicular feres with the mechanics of the foot; they suggest bone. The independent accessory navicular bone that the presence of the bone serves as an irritant is surrounded by the posterior tibialis tendon. A portion of the posterior tibialis tendon inserts on the other two forms of the accessory navicular bone.2 The roentgenogram of the feet may show complete fusion, incomplete fusion, or nonfusion of the accessory navicular bone to the navicular bone.6 The findings of nonfusion and incomplete From the Department of Family Medicine, University of Iowa HospitaI and Clinics, Iowa City, Iowa and Mercy Hospi­ fusion unilaterally with symptoms localized to that tal, Iowa City, Iowa. At the time this paper was written, Dr. foot may lead to a misdiagnosis of a fractured na­ Strayhorn was Chief Resident in family practice, University of Iowa Hospital and Clinics, Iowa City, Iowa. Requests for vicular bone. reprints should be addressed to Dr. Gregory Strayhorn, Microscopically, the accessory navicular and Robert Wood Johnson Clinical Scholars Program, The School of Medicine, University of North Carolina, Chapel the navicular bones have a cancellous trabecular Hill, NC 27514. structure of tarsal bones. The two bones are joined 0094-3509/82/070059-06$01.50 5 1982 Appleton-Century-Crofts

THE JOURNAL OF FAMILY PRACTICE, VOL. 15, NO. 1: 59-64, 1982 59 ACCESSORY NAVICULAR BONE by hyaline cartilate, dense fibrocartilage, or a ing and narrow shoes. Frequently, the first symp­ combination of the two. In younger patients there toms appear after an eversion injury to the foot. can be marked ossification activity on both sides The symptoms may be bilateral or unilateral. The of the fibrous plate between the two bones. A syn­ physician may easily misdiagnose the acute symp­ chondrosis is formed if there is not complete toms that occur after an injury to the foot as a ossification.6 fractured navicular bone if he or she is not familiar with this entity.

Pathology The etiology of the pain and irritation associ­ Differential Diagnosis ated with the accessory navicular bone may be Vertical fractures of the tarsal navicular medial secondary to the inflammation that occurs from tuberosity result from a forced eversion of the direct and repeated trauma to the bone and its at­ foot, usually occurring from a fall from a low tachment to the navicular bone and to its associa­ height.7-8 The local symptoms of a fracture of the tion with the posterior tibialis tendon. A sudden medial navicular tuberosity may go unnoticed for strain on the posterior tibialis tendon from an several hours, but are usually more pronounced eversion injury can cause a partial separation of than those of an injury to the accessory navicular the accessory navicular bone’s fibrocartilaginous bone. One may find moderate diffuse swelling and attachment to the navicular bone and cause a ecchymoses on the medial side of the foot. Ten­ pseudoarthrosis with inflammatory changes. The derness is usually not so localized as that of a accessory navicular bone may cause irritation to symptomatic accessory navicular bone.9 the posterior tibialis tendon when it is embedded Fractures of the tarsal navicular bone involve in or partially surrounded by the tendon. A bursa the medial tuberosity, the dorsal lip, and the may form between the posterior tibialis tendon body.7-10-11 They occur in the vertical and horizon­ and the accessory navicular bone. The bursa can tal plane and are usually comminuted, crushed, or become inflamed and irritated.1-8 chipped fractures.8-12 Because of its anatomical Microscopic findings have shown hemorrhages, relationship to the tarsal navicular bone, the ac­ organizing fibrous tissue containing giant cell os­ cessory navicular bone may be misdiagnosed as a teoclasts or chondroblasts, and callus-like repara­ vertical chipped fracture of the medial tuberosity tive tissue located subchondrally between the of the tarsal navicular bone. The fracture of the accessory navicular and the navicular bones. medial tuberosity, however, rarely occurs in iso­ These findings explain the acute and localized lation. There is commonly an associated tear of symptoms in patients with an accessory navicular the posterior tibialis tendon and ligaments that bone.6 support the surrounding joints, which results in joint deformity. Fractures of the surrounding bony structures are usually encountered.7-9 The fracture fragment is usually irregular at the fracture line and asymmetrical, unlike the accessory navicular bone, which tends to be symmetrical with smooth Symptomatology surfaces (Table l).12 The patient who has symptoms associated with the accessory navicular bone usually presents to the physician with pain localized to the medial sur­ face of the foot. The patient tends to be in his or her teens or early adulthood, and the pain is acute or chronic. There is usually a palpable protuber­ Treatment ance with swelling and redness where the pain is Conservative treatment of symptoms that are localized. The pain is aggravated by weight bear- associated with the accessory navicular bone

60 THE JOURNAL OF FAMILY PRACTICE, VOL. 15, NO. 1, 1982 ACCESSORY NAVICULAR BONE

Table 1. Differential Clinical and Radiographic Findings of a Symptomatic Accessory Navicular Bone (SANB) and a Fractured Navicular Bone (FNB)

SANB FNB

Precipitating Event None + Forced eversion of foot + + + ± Forced eversion and fall + + + + + from low height Clinical Symptoms Swelling Diffuse + + + Localized + + ± Discoloration Erythema + + Ecchymoses - + + + Tenderness Diffuse + + Localized + + + Fiadiographic Findings Symmetrical and smooth margins + + + Joint space deformity - + + Fracture of adjacent bones + +

-N ot present ±Present infrequently +May be present + +Frequently present + + +Almost always present

consists of arch supports, heel wedge with arch month orthopedic rotation. Information obtained supports, warm soaks, strapping, anti-inflamma­ from the charts were age, sex, presenting com­ tory medication, and casts. The conservative plaints, physical examination findings, initial man­ methods offer varying success of symptomatic re­ agement of symptoms, operative findings, postop­ lief that may not be long lasting. The definitive erative treatment, and outcome of treatment. treatment for permanent relief of refractory symp­ The findings of the chart review for three female toms related to the accessory navicular bone is and two male patients are listed in Table 2. Their surgical excision of the bone. ages ranged from 13 to 37 years, with four patients being under 25 years. Four patients had the onset of symptoms after a twisting or eversion injury to the involved foot or ankle. One patient had a grad­ ual onset of pain, not associated with an injury, occurring over a six-month period. Chart Review On physical examination all patients had pain to Charts of five patients were reviewed from the palpation over the area of the accessory navicular practice of a private orthopedic surgeon who bone or the posterior tibialis tendon. Eversion of teaches family practice residents during their two- the foot and plantar flexion aggravated the pain.

THE JOURNAL OF FAMILY PRACTICE, VOL. 15, NO. 1, 1982 61 ACCESSORY NAVICULAR BONE

Table 2. Summary of Chart Review

Presenting Physical Initial Operative Postoperative Patient Complaints Examination Management Findings Treatment Outcome

1. 24-year- Six-month his- Swelling, medial None Large bone Short leg cast in Pain free 4'/2 old male tory of gradual- aspect right fragment ex- slight varus years after onset severe, ankle. Firm 7 to 8 tending into position for com plete heal- sharp pain in mm mass in del- deltoid three weeks. ing medial right toid ligament ligament and Gradual in- ankle, aggra- distal to tip im pinged crease in activity vated by walking o f medial against after cast re- on uneven ter- m alleolus. Pain posterior tibialis m oval rain. Aching increased with tendon. It was pain at rest eversion and attached to plantar flexion. navicular bone X-ray film by dense fibrous showed bony tissue mass im ­ mediately distal to medial mal­ leolus, which appeared to arise from medial aspect o f talus

2. 13-year- Three-year his- Swelling, medial None Accessory Short leg cast Asymptomatic old female to ry o f pain in aspect of foot navicular bone for 10 days. 3'/2 years after medial aspect of over the navicu- joined to the Weight bearing cast removal left foot just lar bone. Pain navicular bone as tolerated after anterior and in- increased with by a shaqqv cast removal ferior to the palpation di- reddish cartilage ankle. Pain rectly over in the facet o f began after posterior tibial the navicular twisting foot. tendon. X-ray bone Pain increases film showed with running cystic changes at junction of the navicular and accessory bones (Continued)

Two patients had some swelling evident, but no malleolus that appeared to arise from the medial redness was observed. One patient had a 15° de­ aspect of the talus, respectively (Figure 1). crease in full dorsiflexion of the foot. Another pa­ Conservative treatment was initiated for two tient had a pes planus deformity. patients with a short leg walking cast for three Radiographic findings on four patients revealed and four weeks, respectively. The patients were cystic changes at the junction of the accessory symptom-free following the removal of the cast; navicular and the navicular bones, a small acces­ however, symptoms recurred after three to four sory navicular bone with mild reactive changes, weeks of gradual increase in weight-bearing activ­ and a bony mass immediately distal to the medial ity.

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Table 2. Continued

Presenting Physical Initial Operative Postoperative Patient Complaints Examination Management Findings Treatment Outcome

3. 22-year- Six-week history 15° lack of Short leg cast Accessory Compression Asymptomatic old female of pain in medial full dorsiflex- for one month, navicular at- dressing after complete aspect of right ion of foot. Pain followed by tached to applied. Ambu­ healing foot beginning increased with gradual in­ navicular bone lation with after an eversion eversion of foot. creased activity by fibrocartilage touch, weight­ injury to foot. Tenderness over bearing crutches Diagnosed ini­ accessory tially as fracture navicular bone o f sm all bone in and posterior foot. Short leg tibial tendon cast was worn fo r 3 weeks. Pain recurred after cast removal

4. 37-year- One-year history Palpable pain None Accessory Short leg cast Asymptomatic 4 old male o f pain in medial over accessory navicular em­ for 18 days. years after cast aspect of right navicular bone. bedded in the Weight bearing removal foot beginning Pain aggravated posterior tibial as tolerated after after twisting in­ by eversion of tendon cast removal ju ry to foot. Pain foot. X-ray film aggravated by showed small weight bearing. accessory Patient unable to navicular bone wear shoes with mild re­ comfortably active changes

5. 18-year- Several months' Mild pes planus Immobilization Accessory Short leg cast Asymptomatic 9 old female history of pain deform ity. w ith short leg navicular with fo r 3 weeks. months after and sw elling in Swelling and walking cast for shaggy Weight bearing cast removal medial aspect of tenderness over 4 weeks. Pain pseudoarthrosis as tolerated after right foot. Pain posterior tibial recurred after and obvious cast removed aggravated by tendon. X-ray cast removed m otion weight bearing. film showed an Sprained ankle accessory bone. prior to pain

All the patients had surgical excision of their postoperatively. One patient had a compression accessory navicular bones. Four patients had ac­ dressing applied to the foot, and ambulation was cessory navicular bones that were attached to the permitted with touch weight-bearing crutches. The navicular bone by a fibrocartilaginous tissue. A casts and compression dressing remained on for a pseudoarthrosis with obvious motion was found in period of ten days to three weeks. All patients one patient. One accessory navicular bone was were asymptomatic after complete healing of their embedded into the posterior tibialis tendon. surgical wounds. There were no entries on the Four patients were placed in a short leg cast charts that suggested further symptoms.

THE JOURNAL OF FAMILY PRACTICE, VOL. 15, NO. 1, 1982 63 ACCESSORY NAVICULAR BONE

Figure 1. Radiographic and diagrammatic representation of accessory navicular bone (patient 4), antero­ posterior (A, B) and lateral (C, D) views. Shaded areas (B, D) define accessory navicular bone

Summary References 1. Geist ES: The accessory scaphoid bone. J Bone Joint Surg 7:570, 1925 The literature review and clinical review of the 2. Veitch JM: Evaluation of the Kidner procedure in treatment of symptomatic accessory tarsal scaphoid. Clin etiology of the symptoms associated with the O rthop 131:210, 1978 accessory navicular bone suggest that this bone 3. Chater EH: Foot pain and the accessory navicular bone. Irish J Med Sci 442:471, 1962 serves as a nidus for local irritation and inflamma­ 4. Kidner FC: The pre-hallux in relation to flatfoot. tion. Surgical excision of the bone appears to be JA M A 101:1539, 1933 5. Sullivan JA, Miller WA: The relationship of the ac­ the treatment of choice for the permanent resolu­ cessory navicular to the development of the flat foot. Clin tion of symptoms in some patients. Knowledge of Orthop 144:233, 1979 6. Zadek I, Gold AM: The accessory tarsal scaphoid. J the possible presence of an accessory navicular Bone Joint Surg 30-A:957, 1948 bone may aid the family physician in making the 7. Main BJ, Jowett RL: Injuries of the mid tarsal joint. J Bone Joint Surg 57B:89, 1975 proper diagnosis in a patient who has symptoms 8. Rogers L, Campbell RE: Fractures and dislocations localized to this area of the foot. When conserva­ of the foot. Semin Roentgenol 13:157, 1978 9. Denwar FP, Evans DC: Occult fracture subluxation tive treatment fails, early referral of the patient to of the midtarsal joint. J Bone Joint Surg 50B:386, 1968 an orthopedic surgeon for surgical excision of the 10. Eftekhar SN, Levine DB: Fractures of the tarsal na­ vicular bone. Clin Orthop 39:142, 1964 bone may decrease the morbidity and the length of 11. Nadeau P, Templeton J: Vertical fracture dislocation inconvenience that is associated with a sympto­ of the tarsal navicular. J Trauma 16:669, 1976 12. Zatzkin HR: Trauma to the foot. Semin Roentgenol matic accessory navicular bone. 5:419, 1970

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